A Clinical Judgment Approach 4th
Edition
• Author(s)Sharon Jensen; Ryan Smock
TEST BANK
1. Reference: Ch. 1, Section: The Nurse’s Role in Health
Assessment. shop.lww.com
Question Stem: A newly licensed RN is preparing to perform a
comprehensive admission assessment on a stable adult. Which
action best reflects the RN’s role as provider of care during this
assessment?
A. Delegating the entire admission history to a nursing assistant.
B. Completing a focused exam only on the system the patient
complains about.
C. Performing a full head-to-toe physical exam and documenting
findings.
D. Referring the patient immediately to an advanced practice
provider for diagnosis.
Correct Answer: C
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,Rationale — Correct: Performing a full head-to-toe exam and
documenting is central to the RN’s provider role, collecting data
to plan care (Ch.1).
Rationale — A: Delegating the entire history to a nursing assistant
abandons professional responsibility; RNs must collect or directly
validate assessment data.
Rationale — B: A focused exam may be appropriate sometimes,
but a comprehensive admission requires head-to-toe assessment
for baseline data.
Rationale — D: Referring is appropriate for scope issues, but
routine comprehensive assessment is within the RN’s role and
needed before referral.
Teaching Point: RN conducts and documents comprehensive
baseline assessments.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment. shop.lww.com
2. Reference: Ch. 1, Section: Advanced Practice Registered
Nurse (APRN) vs RN assessments. shop.lww.com
Question Stem: A patient asks why an APRN is conducting a
diagnostic procedure while the RN only performs nursing
assessments. Which explanation best describes the difference? A.
APRNs focus solely on psychosocial needs; RNs only record vitals.
B. APRNs can diagnose and prescribe; RNs assess, identify
problems, and implement nursing interventions.
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C. RNs are not qualified to perform physical exams.
D. APRNs and RNs have identical legal scopes of practice in all
settings.
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Correct Answer: B
Rationale — Correct: APRNs have authority to diagnose and
prescribe; RNs focus on assessment, nursing diagnoses, and
interventions within their scope.
Rationale — A: Incorrect — roles are not limited to those
extremes; both consider psychosocial needs and vitals.
Rationale — C: Incorrect — RNs routinely perform physical
exams and assessment techniques within their scope.
Rationale — D: Incorrect — scopes differ by licensure and
regulations; they are not identical.
Teaching Point: APRNs diagnose/prescribe; RNs assess and
implement nursing care.
Citation: Jensen & Smock, Ch. 1, The Nurse’s Role in Health
Assessment. shop.lww.com
3. Reference: Ch. 1, Section: Teaching and Health Promotion;
Wellness and Illness. shop.lww.com
Question Stem: During discharge teaching, the nurse identifies
the patient’s stage of illness and readiness to learn. Which
action best demonstrates evidence-based health promotion? A.
Providing a detailed 20-page leaflet regardless of literacy level.
B. Tailoring teaching to the patient’s readiness, culture, and
health literacy.
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